DATE
Rodolfo G. Ramos Jr., DDS, PC
Board Presiding Officer
Texas State Board of Dental Examiners
333 Guadalupe, Tower 3, Suite 800
Austin, Texas 78701-3942
Dear Dr. Ramos and Dental Board:
As a citizen and clinician in the state of Texas, I appreciate the opportunity to provide
comments to the Texas State Board of Dental Examiners (TSBDE) regarding the proposed
regulations for Texas Administrative Code (TAC) §108.12, Dental Treatment of Sleep
Disorders.
I recognize the beneficial role that dentists can play in the provision of custom fabricated oral
appliances for appropriate patients with obstructive sleep apnea (OSA) and other forms of
obstructive respirations. However, I again strongly object to much of the language in the
revised version of the proposed rule issued by the TSBDE on March 28. This proposal, which
will be considered for final adoption at the upcoming May meeting, would violate the Texas
Medical Practice Act and jeopardize the quality of care for patients in Texas who have sleepdisordered breathing.
I fervently oppose the proposed language allowing a dentist to use a sleep study as a
screening device. In contrast to questionnaires, sleep studies are not screening tools. A sleep
study is a diagnostic procedure that must be ordered by a licensed physician, performed
according to AASM practice parameters and clinical guidelines, and interpreted by a
board certified sleep medicine physician. Therefore, the AASM supports the recent
position statement of the Texas Medical Board, which declares emphatically that only a
licensed physician can order a sleep study.
Furthermore, I object to the proposed language which recommends the “consideration of
referral” to a physician. Snoring and OSA, a chronic medical disease that often co-occurs
with other sleep disorders as well as other serious medical conditions that require the ongoing
supervision of a physician, are classified as medical diagnoses in both the International
Classification of Diseases (ICD) and the International Classification of Sleep Disorders
(ICSD). If a patient reports snoring, then referral to a physician is required to determine if
the snoring is benign or symptomatic of OSA. Following this medical diagnosis the
physician will prescribe the most appropriate course of treatment.
The diagnosis of sleep-disordered breathing, including sleep apnea, must be made by a
qualified physician in order to protect the health and safety of patients. Although the
American Board of Dental Sleep Medicine has established a pathway to recognize dentists
who are proficient in providing oral appliance therapy for sleep-disordered breathing, it is
outside of the scope of dentistry to allow any dentist to make a diagnosis of a sleep disorder
independent of a physician.
Dental sleep medicine has not been recognized as a specialty by the American Dental
Association (ADA), and dental school curriculum fails to include didactic instruction on
upper airway obstruction and the pathophysiology of OSA. Therefore, it is inappropriate to
consider expanding the scope of practice for dentistry to include the diagnostic aspects of
sleep medicine. Only a licensed physician is qualified to identify the cause of sleepdisordered breathing, monitor potential complications of the disorder, and prescribe
appropriate treatment. This principle is supported by the Texas Medical Board, the Texas
Medical Association, the American Academy of Sleep Medicine, and the American Academy
of Dental Sleep Medicine.
Sleep medicine is a recognized medical subspecialty with both fellowship training programs
that are accredited by the Accreditation Council for Graduate Medical Education (ACGME)
and a board certification examination that is offered by six sponsoring boards of the
American Board of Medical Specialties (ABMS). This training has uniquely qualified
thousands of board certified sleep medicine physicians to provide high quality,
comprehensive, long-term medical care for patients with any form of sleep-disordered
breathing, including snoring, UARS and OSA.
Accessibility to care is challenging in remote regions of our state where a sleep specialist
may not be located within a reasonable commute. Appropriate protocol is for patients to be
evaluated by a physician who can work in conjunction with a local dentist when necessary. It
is ineffectual and unlawful for the local dentist to work independently on patients who have
sleep-related breathing issues.
The proposed rule would endanger patients, threaten public safety and expose dentists to
medical malpractice liability. The TSBDE has the responsibility to protect the public from
inappropriate dental practices. It is clear that the current rule proposal would easily allow
dentists to practice inappropriately by labeling patients as having snoring or UARS without
proper assessment for the secondary gain of independently providing OAT without a
physician evaluation.
I urge the TSBDE to amend the proposed rule as advised. In addition, I respectfully ask
that the TSBDE cease proposing rules that infringe upon the physician scope of practice.
I thank you for taking my input into consideration.
Sincerely,
Name